By: RodrÃguez S.B. No. 1419
A BILL TO BE ENTITLED
AN ACT
relating to the establishment of the independent provider health
plan monitor for certain appeals in the Medicaid managed care
program.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Chapter 533, Government Code, is amended by
adding Subchapter F to read as follows:
SUBCHAPTER F. INDEPENDENT PROVIDER HEALTH PLAN MONITOR
Sec. 533.301. DEFINITION. In this subchapter, "monitor"
means the person serving as the independent provider health plan
monitor under this subchapter.
Sec. 533.302. ESTABLISHMENT. (a) The commission shall
establish the position of independent provider health plan monitor
within the commission.
(b) The independent provider health plan monitor shall
create an independent review process that utilizes the standards of
the Independent Review Organization process under Section
4202.002, Texas Insurance Code.
Sec. 533.303. REVIEW OF CORRECTIVE ACTIONS. (a) A health
care provider in the managed care organization's provider network
may petition the monitor in the form and manner provided by
commission rule to review a corrective action taken by a managed
care organization that is not agreed to by the provider in
connection with, but not limited to, pre-authorization denials,
reimbursement, standard of care, a claim payment denial,
disagreement about medical or treatment necessity, or compliance
with commission rules and contractual terms.
(b) The monitor shall review a case submitted under
Subsection (a) and issue a decision in accordance with this
subchapter.
Sec. 533.304. PROCEDURES. (a) The monitor shall:
(1) provide written notice of the submission of a
petition under Section 533.303 to the party
opposing the party that submitted the petition;
and
(2) allow the opposing party to submit evidence to the
monitor not later than the:
(A) 10th day after the monitor provided the
notice for petitions involving
pre-authorizations, or medical or treatment
necessity denials, or
(B) 30th day after the date the monitor provided
the notice for all other petitions.
(b) Not later than the 30th day after the deadline for the
submission of evidence under Subsection (a), the monitor shall
provide written notice to the parties of the monitor's decision for
the case.
(c) While the review process or an appeal by either a
provider or the managed care organization is ongoing, the managed
care organization shall not recoup any funds or otherwise penalize
a provider.
(d) In reaching a decision under Subsection (b), the monitor
shall conduct interviews with all relevant parties and review any
submitted documentation and other evidence to determine whether:
(1) the managed care organization complied with:
(A) applicable commission rules; and
(B) the organization's internal policies and
procedures for auditing or taking a corrective action against a
health care provider; and
(2) the health care provider:
(A) complied with applicable commission rules;
(B) submitted required documentation in
accordance with the law; and
(C) engaged with a recipient.
(e) The decision made by the monitor shall be binding unless
appealed by the provider or the managed care organization.
(f) An adverse decision against a managed care organization
shall be registered as a verified complaint within the commission's
system and shall be subject to any appropriate penalties by the
commission.
(g) An adverse decision against a managed care organization
shall be subject to the prompt payment penalty from the beginning
date of the late payment.
Sec. 533.305. APPEAL. A managed care organization or
health care provider may appeal the monitor's decision under
Section 533.304 to the State Office of Administrative Hearings.
Sec. 533.306. REPORT. The monitor shall compile and
provide an annual report to the commission on:
(1) the number of corrective actions reviewed by the
monitor for which petitions were submitted by a health care
provider;
(2) the number of corrective actions reviewed by the
monitor for which petitions were submitted by a managed care
organization;
(3) the number of corrective actions overturned by the
monitor;
(4) the number of corrective actions upheld by the
monitor;
(5) the reasons for submissions by health care
providers of petitions to the monitor;
(6) the amount of money managed care organizations
recovered in corrective actions upheld by the monitor; and
(7) the amount of money reimbursed to health care
providers through corrective actions overturned by the monitor.
SECTION 2. As soon as practicable after the effective date
of this Act, the executive commissioner of the Health and Human
Services Commission shall adopt rules necessary to implement
Subchapter F, Chapter 533, Government Code, as added by this Act,
and the commission shall establish the position of independent
provider health plan monitor under that subchapter.
SECTION 3. If before implementing any provision of this Act
a state agency determines that a waiver or authorization from a
federal agency is necessary for implementation of that provision,
the agency affected by the provision shall request the waiver or
authorization and may delay implementing that provision until the
waiver or authorization is granted.
SECTION 4. This Act takes effect September 1, 2019.